HomeMy Public PortalAbout5826 ALESSANDRO AVE_Building__ APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUI G ADo ESS
I hereby affirm that I have a certificate of consent to self insure, BUILDING AD RESS
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.�3800,Lab.C.) „�� CIS ZIP . / LOCALITY
Polic Y I! Company a SIZ O LOT [N-0 10F BLDGS.NOW ON LOT
Certified copy is hereby furnished. NEAREST CROSS ST.
❑ Certified copy is filed with th�count �inspectio TRACT BLOCK LOT NO.yUSEZONE MAP NO.
dep��artm-77rern,.,,tL��^^77 DateJif-_L2 Applicant �' ASSESSOR MAP BOOK PAGE PARCEL A SPECIAL CONDITIONS
OWNER TEL.NO. /may
CERTIFICATE OF EXEMPTI FROM WORKERS' YES NO
COMPENSATION INSURANCE N.QB WITHIN 1000 FT.OF SCHOOL?
A S
(This section need not be completed if the permit is for one hundred i DISTRICT 'GROUP TYPE CONST. FIRE ZONE PROCESSED BY
dollars($100)or less.) CITY,,.—,
I certify that in the performance of the work for which this permit /
is issued, I shall not employ any person in any manner so as to ARCHrrECT OR ENGINEER TEL.NO.
become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO
Date Applicant 'ADDRESS CLASS NO. DWELL UNITS
NOTICE TO APPLICANT. If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST
C�O
Exemption, you Should become subject t0 the Workers' CONTRATEL.rJO. SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions of the Labor Code, you must forthwith (/ FRONT
comply with such provisions or this permit shall be deemed revoked. ADDR S LIC. Q.�f P L
Af
LICENSED CONTRACTORS DECLARATION CITY ter LIt.CLASS PIIL
1 hereby affirm that I am licensed under provisions of Chapter 9 0 'T SEWER MAP v'
(commencing with Section 7000)of Division 3 of the Business and SQ•FT SIZEv NO. STORES NO. FAMILIES C)
Professions Code,and my license is in full force and effect. NEW ❑ BK PG 0
RIPTION OF WORK ADD ❑ VALUATION_ , W
License Number Lic.Class _ ,may
/ '9 ALTER ❑ G/
Contractor ate Z
1 t Iwco -
❑ I am exempt under Sec. REPAIR
B.&P.C.for this reason DEMOL ',❑ LDMA P/C It
Date' USE OFEXISTING BLDG. URM. ❑
Signature APPLICANT(PRINT) TEL.NO. LDMA Perm# {:
a
❑ I, as owner of the p rty, or my employees with wages as p s -
their sole compensat will do the work and the structure is ADDRESS _ ,� __._. ��,�(}?,..._...,.. .._ �.rfi��..63
not intended or offered for sale (Section 7044, Business and FINALDATE, Q
PfOfeSSIOr1S Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL •' O j � � _
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN Q YF. "'9
❑ 1, as owner of the property, am exclusively contracting with THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY `��`q > TC
I HL 1•d�R-,.r ® 9�+,.'�b
licensed contractors to construct the project.(Section 7044, YES❑ NO❑
Business and Professions Code.) f HECK 14.6L
WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING' _
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH' CHANGE
y,4/�
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST /)� y[/�/� ////� L•� !iSJE a � j
FOR GUIDELINES.
I hereby affirm that there is a construction lending agency for YES 1:1NO Elthe performance of the work for which this permit is issued(Sec.
3097,CIV.C.. 1 HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD — 11oco-.I31 L[iW i A 1f 7/C,}•y
PERMITTING CHECKLIST.1 UNDERSTAND MV REQUIREMENTS UNDER THE LOS ANGELS � __ '
COUNTY CODE,TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING
m Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. 4// 7495 1 AM 10 a 04
3 Lender's Address
d OWNER OR AGENT
o I certify that I have read this application and state that the above
information is Correct. I agree to comply with all county P.C.FEE PERMIT FEE
ordinances and State lays relating to building construction,and
herefe-Merntioney
uize rep s ntatives of this County to enter upon ISSUANCE FEE
thep operty for Pspection purposes.
f
a INVESTIGATION FEE TOTAL FEE ` ?
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"7 .7� �O ✓
Signature of Applicant Agent lata
SEE REVERSE FOR EXPLANATORY LANGUAGE